Crestway Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer all residents to PASARR with newly evident or possible serious mental disorder for level II resident review for 1 of 6 Residents (Resident #4) whose records were reviewed for PASARR assessments. The facility failed to refer Resident #4 for PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation when Resident #4 was diagnosed with Major Depressive Disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) on 4/1/23 and undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) on 2/16/24. This deficient practice could affect residents diagnosed with mental disorders and could result in the residents not receiving the necessary services from PASARR.The findings were:Based on interview and record review the facility failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 18 residents (Resident #55) reviewed for care plan revision/timing. The facility failed to ensure Resident #55's care plan addressed changes in his smoking status regarding the resident could keep his cigarettes and lighter because he was very safe smoker after smoking assessment, dated 05/08/2025. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health. Findings included:Record review of Resident #55's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male and admitted to the facility originally on 11/14/2024 and re-admitted on [DATE] with diagnoses of dry eye syndrome bilateral lacrimal glands (inflammation of the tear-shaped gland), fatty liver (fat builds up in the liver), paraplegia (loss of muscle function in the lower half of the body), hypertension (high blood pressure), and dysuria…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 1 Resident (Resident #9) whose records were reviewed for assessments. LVN/Treatment Nurse K failed to assess Resident #34's feet during a head-to-toe assessment and did not identify he had significantly long toenails and two ingrown toenails. This deficient practice could affect any resident and could contribute to pain, infections and loss of toes. The findings were:Review of Resident #9's face sheet, dated 7/17/25, revealed he was admitted to the facility on [DATE] with diagnosis including Critical Illness Myopathy (generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness and is associated with significant morbidity and mortality). Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #62) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #62 on 07/17/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included:Record review of Resident #62's face sheet, dated 07/18/2025, revealed the resident was a [AGE] year-old female and admitted to the facility originally on 06/06/2025, and re-admitted on [DATE] with the diagnoses of type 2 diabetes mellitus (not control blood sugar in the body), necrotizing fasciitis (serious bacteria infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #17) of 2 residents reviewed for enteral nutrition. When LVN-B flushed Resident #17's gastrostomy tube with 30 ml of water, LVN-B pushed water inside the barrel of the syringe with a plunger, instead of using gravity. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included:Record review of Resident #17's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of personal history of covid-19, seizures (sudden burst of electrical activity in the brain), peritonitis (redness and swelling of the lining of the belly or abdomen), hypertension (high blood pressures), and gastro-esophageal reflux disease (the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 1 of 9 (Cart #1 on 400 hall) medication carts observed for expired medication in that: The facility failed to remove expired medications from medication cart #1 1 bottle of Gentle Lax and 1 bottle of Extra Strength Tylenol 500mg This failure could result in residents decreased health response or misuse of medication.Findings included: Observation on 07/16/2025 at 10:40AM medication cart 1 of 4 for #400 hall revealed 1 bottle of Gentle Lax with an expiration date of 03/2025 and 1 bottle of Acetaminophen 500mg with expiration date of 04/2025. Interview on 7/16/2025 at 10:45AM LVN B said he missed the expiration dates on the medications. He said it would not be safe to give because it could cause an adverse reaction to the resident or it may not be as effective to use for effective results. Interview on 7/16/2025 at 11:10AM the DON said expired medications would not be as effective or not be able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #7) out of 18 residents reviewed for medical records. Resident #7's psychiatric doctor added the resident's general anxiety as one of the resident's diagnosis and prescribed diazepam 2 mg three times a day for anxiety, but the facility did not add the new diagnosis to the resident's medical record. This failure placed residents at risk for missed treatment and medications which could result in decline in heal and well-being.Findings included: Record review of Resident #7's face sheet, dated 07/18/2025, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of abnormal findings in urine, type 2 diabetes mellitus (not control blood sugars in the body), hypertension (high blood pressures), hyperlipidemia (high fat in the body), cystitis (urinary bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #16) of 18 residents reviewed for environmental concerns. Resident #16's oxygen cylinder was stored in the resident room, but per the facility policy indicated Do not oxygen cylinder in any resident room or living area. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included:Record review of Resident #16's face sheet, dated 07/18/2025, revealed the resident [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of dysphagia (difficulty of swallowing), chronic pain, encephalopathy (brain damage), hyponatremia (level of sodium in the blood is too low), and personal history of covid-19. Record review of Resident #16's quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 6 residents (Resident #4) reviewed for residents' rights. The facility failed to ensure LVN A locked the medication cart computer screen and left an unidentified resident's (Resident #4) information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Observation on 6/18/25 at 9:48 a.m. revealed a medication cart was left unlocked and unattended facing the hallway in the 200 hall and the computer screen on top of the medication cart counter was left opened with an Resident # 4's information exposed. Observation and interview on 6/18/25 at 9:49 a.m. revealed LVN A walked out of a resident room from across the hall on the 200 hall and walked up to the unlocked computer screen on top of the medication cart counter exposing an Resident # 4's information. LVN A stated, he had forgotten to lock the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans: The facility failed to ensure Residents #1's comprehensive care plan reflected he received a mechanically altered diet. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #1's face sheet dated 6/18/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of brain, hemiplegia (paralysis) affecting the left dominant side, and aphasia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan was comprehensive and updated to reflect Resident #2 had an indwelling catheter and a stage 4 pressure ulcer to the sacrum. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #2's face sheet dated 6/20/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, heart failure, respiratory failure, dysphasia (medical condition characterized by a partial or total impairment of language ability that affects a person's ability to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #3) reviewed for enteral feeding: LVN C failed to flush Resident #3's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #3's face sheet dated 6/19/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia (deficiency of oxygen reaching the tissues of the body), gastroparesis (condition in which the stomach muscles do not function properly, causing delayed emptying of food from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 2 medication carts reviewed for storage of drugs and biologicals. The facility failed to ensure the medication cart on 200 hall and 300 halls were locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion. The findings included: Observation on 6/18/25 9:48 a.m. revealed a medication cart was left unlocked and unattended facing the hallway in the 200 halls. Observation and interview on 6/18/25 at 9:49 a.m. revealed LVN A walked out of a resident room from across the hall on the 200 hall and walked up to the unlocked medication cart on the 200 hall. LVN A stated he was assigned to the medication cart on the 200 hall. LVN A stated he forgot to lock the medication cart and if unauthorized persons were to get into the medication cart, they could consume medications that did not belong to them and cause an allergic reaction. LVN A stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 1 resident (Resident #1) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #1 was provided with an Adult Sip Cup to meet Resident #1's need for assistance while eating. This failure could place residents at risk for harm from weight loss, diminished independence, and self-esteem. The findings included: Record review of Resident #1's face sheet dated 6/18/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of brain, hemiplegia (paralysis) affecting the left dominant side, and aphasia (language disorder that affects the ability to communicate usually caused by damage to the brain). Record review of Resident #1's most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 5 residents (Resident #4) reviewed for grievances. The facility failed to fully investigate and follow up with Resident #4's and Resident #4's family member about a grievance report on 1/12/25 of being sprayed with an unknown substance by an unknown staff member. This failure could place residents at risk for not having their grievances resolved. The findings included: Record review of Resident #4's admission record dated 3/28/25, revealed a [AGE] year-old female resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included chronic respiratory failure with hypoxia (your lungs have a hard time loading your blood with oxygen or removing carbon dioxide with low levels of oxygen in your body tissues), morbid obesity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's care plans were revised by the interdisciplinary team after each assessment for 1 of 5 Residents (Resident #1) whose records were reviewed for care plan timing and revision, in that:. Resident #1's Care Plan did not reflect she required a mechanical lift for transfers. These deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: Record review of Resident #1's admission record, dated 03/26/25, reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), age-related physical debility, lack of coordination, and acquired absence of left leg below knee. Record review of Resident #1's MDS assessment, dated 10/16/24, reflected Resident #1 was dependent (helper does ALL of the effort) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #2) reviewed for infection control: The facility failed to ensure CNA N and CNA O wore the proper PPE while transferring Resident #3 who was on EBP. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #2's Face Sheet, dated 03/28/2025, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with diagnoses of tracheostomy status (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea. Surgeons place a tracheostomy tube into the hole to keep it open for breathing.), dependence on respirator [ventilator] status (machine or device used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's ordered seizure medications of Lamictal and Phenobarbital on 2/18/2025 and 2/19/2025, resulting in 5 missed doses of Lamictal and 2 missed doses of Phenobarbital. 2. The facility failed to administer Resident #1's medication (Ativan) per physician's orders for two doses on 2/19/2025 and 2/20/2025. This PRN medication was ordered to be administered as needed for seizure and was administered for agitated and anxious behaviors. These failures could place residents at risk of increased seizure activity, unintended effects of a medication, or decline in health. Findings include: Record review of Resident #1's face sheet, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for two (Resident #2 and Resident #3) of seven residents reviewed for privacy. 1. The facility failed to ensure CNA A completely closed Resident #2's privacy curtain and obstructed Resident #2's AEM while providing incontinent care. 2. The facility failed to ensure Resident #3 had a signed consent and was not captured within view of his roommate's AEM. These failures could place residents at risk of being exposed and at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem. The findings included: 1. Record review of Resident #2's admission Record, dated 02/20/2025, reflected a [AGE] year-old male.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #4) of 5 residents reviewed for care plans. The facility failed to implement and ensure Resident #4 was assessed for physical and occupational therapy as care planned, dated 10/25/24. This deficient practice could place residents at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The findings included: Record review of Resident #4's admission Record, dated 02/25/2025, reflected a 61- year-old male. He was admitted to the facility on [DATE]. Record review of Resident #4's Medical Diagnosis list, undated but accessed 02/25/2025, reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 1 (Resident #4) of 5 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #4 received PT/OT/ST evaluations and treatments per physician order dated 11/15/2024. This deficient practice could place residents who required rehabilitative services at risk of a decline or decrease in their physical capabilities. The findings included: Record review of Resident #4's admission Record, dated 02/25/2025, reflected a 61- year-old male. He was admitted to the facility on [DATE]. Record review of Resident #4's Medical Diagnosis list, undated but accessed 02/25/2025, reflected Resident #4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #1) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when Resident #1 was administered another resident's medications, atorvastatin (medication to treat high cholesterol), labetalol (medication to treat high blood pressure), and hydralazine (medication to lower blood pressure) by LPN A on 11/09/2024. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings included: Record review of Resident #1's admission Record, dated 02/06/2025, reflected Resident #1 was a [AGE] year-old female. She was initially admitted on [DATE] and readmitted on [DATE]. She was noted to have diagnoses including anoxic brain damage (a condition in which the brain loses oxygen supply which could cause serious, permanent brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 4 residents reviewed for infection control. 1. The facility failed to ensure LVN A and CNA B wore a gown while providing wound care and peri care to Resident #1 who was on EBP (enhanced barrier precautions) on 1/25/2025. 2. The facility failed to ensure LVN A who was the weekend wound care nurse used appropriate infection control principles including wound care cleansing technique, hand hygiene/glove changes during care on 1/25/2025. These deficient practices affect residents who require assistance and wound care treatments and could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed an admission date of 1/23/2025 with diagnoses which included: anoxic brain damage (damage to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the right to personal privacy during personal care for 4 of 5 residents (Resident #5, Resident #6, Resident #7, and Resident #8) reviewed for dignity. 1. The facility failed to ensure Resident #5 was provided with privacy when checking for incontinence. 2. The facility failed to ensure Resident #6 was provided with privacy during incontinent care. 3. The facility failed to ensure Resident #7 was provided with privacy when checking for incontinence. 4. The facility failed to ensure Resident #8 was provided with privacy during incontinent care. These failures could affect residents by contributing to poor self-esteem, and decreased self-worth and quality of life. Findings included: 1. Record review of Resident #5's admission Record, dated 11/22/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Hypertension (high blood pressure), Type 2 diabetes (condition in which the body has trouble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 6 medication carts (Respiratory Treatment Cart #1 and Wound Treatment Cart #2) reviewed for medication storage. 1. The facility failed to ensure the respiratory treatment cart on the 300 hall was locked. 2. The facility failed to ensure the wound treatment cart was locked on (2) occasions. This failure could place residents at risk of medication misuse and drug diversion. Findings included: 1. Observation and interview on 11/21/24 at 10:54 am revealed Respiratory Treatment cart #1 on the 300 hall was observed to be unlocked and unattended by the state investigator and the DON. There were mobile residents moving throughout the facility. RT H said the treatment cart was not supposed to be left unlocked. The DON said there were no medications in the cart and it only had respiratory supplies,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 7 residents (Residents #1, Resident #2, Resident #4, Resident #5, and Resident #6, Resident #7, and Resident #8) reviewed for infection control. 1. The facility failed to use proper infection control practices during perineal care for Resident #1. 2. The facility failed to use proper infection control practices when checking Resident #2 for incontinence. 3. The facility failed to use proper infection control practices during incontinent care for Resident #4. 4. The facility failed to use proper infection control practices when checking Resident #5 for incontinence. 5. The facility failed to use proper infection control practices during perineal care for Resident #6. 6. The facility failed to use proper infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #8) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #8's following care areas: Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling catheter, Psychosocial Well-Being, Activities, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, Physical Restraints, and Functional Abilities related to self-care and mobility. This deficient practice could affect residents and place them at risk for not having their needs and preferences met. Findings included: Record review of Resident #8's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals, and preferences for 2 of 2 (Resident #8 and Resident #9) reviewed for respiratory care. 1. The facility failed to ensure the aerosol tubing for Resident #8 was replaced after it was found on the floor. 2. The facility failed to ensure the aerosol tubing for Resident #9 was replaced after it was found on the floor. This deficient practice could affect residents and place them at risk for respiratory infection and decline in health. Findings included: 1. Record review of Resident #8's admission Record, dated 11/22/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Acute/Chronic Respiratory Failure (lung damage preventing adequate oxygenation of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 6 residents (Resident #1) reviewed for administration: The facility failed to ensure Resident #1's Nurse Note, dated 9/29/24 and authored by LVN A, documented the insertion of a suprapubic catheter (a surgically created tube that drains urine from the bladder through a small incision in the lower abdomen) and urine output. Also, LVN A stated she did not check and document catheter care on 9/29/24. This failure could result in residents receiving catheter care not receiving continuity of care and a diminished quality of life. The findings were: Record review of Resident #1's face sheet, dated, revealed an admission date of 9/1/23 and discharged [DATE] to hospital with diagnoses that included: dissection of vertebral artery (surgery to the spine), bacterial infection, unspecified, neuromuscular dysfunction of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 11 residents (Resident #2) reviewed for infection control, in that: The facility failed to ensure Resident #2's catheter bag was anchored on the bed rail and not lying on the floor. This failure could result in the spread of disease and expose residents with catheters to infections and a diminished quality life. The Findings were: Record review of Resident #2's face sheet, dated 10/02/24, reflected a [AGE] year-old female, with an admission date of 09/19/24 and a re-admission date of 10/1/24 with diagnoses that included: type 2 diabetes (primary), a history of UTI (urinary tract infection), and end stage renal disease. The RP was listed as self. Record review of Resident#2's admission MDS (minimum data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the reach in refrigerator were labeled after opened. This failure affect the residents who received meals from the kitchen and place them at risk for foodborne illness. Findings included: Observation of the facility's reach in refrigerator on 05/23/2024 at 9:03 AM revealed two open (1) gallon jugs of ranch dressing unlabeled. Interview with the Dietary Manager (DM) on 05/23/2024 at 9:05 AM revealed all food was to be labeled after being open and stored either in the refrigerator, freezer, or in the dry storage. The DM stated staff were trained by her, when they started, that all food was to be labeled with the date opened and date to be used by after it was opened. The DM stated that all staff were responsible to label open food being stored. Record review of the facility's policy named Food Receiving and Storage dated 2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were accurately documented for 5 of 30 residents (Residents #14, #20, #27, #32, and #236) , reviewed for administration. The facility failed to ensure blood pressures for Residents #14, #20, #27, #32, and #236 were documented as the same on different shifts on the same days when administering blood pressure medications. This failure could result in decreased continuity of care, medication errors, illness, and inaccurate assessments. The findings were: Record review of Resident #14's face sheet dated 5/31/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. The diagnoses included essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). Record review of Resident #14's quarterly MDS assessment dated [DATE] revealed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #27), reviewed for care plans. Resident #27 had an order to remove his mitten restraints every 2 hours for ten minutes but the care plan documented to visually observe the mitten restraints every 2 hours. This failure could place residents at risk of not receiving necessary services to meet their needs, pain, blood flow complications, and contractions. The findings were: Record review of Resident #27's face sheet dated 5/30/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. The diagnoses included other speech and language deficits following cerebral infarction (speech and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for documentation. Resident #'1's electronic medical record did not contain complete and accurate documentation that the resident received three meals on 3/9/24 and 3/10/24. This failure could result in residents' records not accurately documenting delivery of meals, any assistance provided to the resident in consuming meals,; and could result in documentation not showing meal consumption, loss of weight and dehydration, and a diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 3/18/24, revealed, the resident was admitted on [DATE] with diagnoses that included: dystonia (neurological disease), HTN (hypertension), and contractures. The resident was a female at the of age [AGE]. The RP was listed as: a family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 8 of 20 residents (Residents #11, #8, #14, #16, #5, #12, #2, and #10) reviewed for respiratory care in that: The facility did not ensure Residents #11, #8, #14, #16, #5, #12, #2, and #10 had an order to deflate their tracheostomy tube [a tube that is inserted through a hole in the neck and into the windpipe to assist with breathing] cuffs. This deficient practice could affect residents and result in infection, not receiving therapeutic benefits of oxygen, diminished quality of life, and respiratory compromise. The findings were: Record review of Resident #11's face sheet, dated 1/23/24, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of sepsis [a blood infection], unspecified organisms, essential (primary) hypertension, acute respiratory failure with hypoxia [low levels of oxygen in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify, consistent with his or her authority, a resident's representative when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 20 residents (Resident #4) reviewed for notification of changes in that: The facility failed to notify Resident #4's responsible party when Resident #4 had unexpectedly removed her tracheostomy tube [a tube inserted through the neck and the windpipe to assist with breathing] and was immediately transferred to a local hospital. This deficient practice could place residents at risk not having their responsible party notified of changes. The findings were: Record review of Resident #4's face sheet, dated [DATE], revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypothyroidism [when the thyroid does not produce enough hormones], unspecified, Vitamin D deficiency, unspecified, hyperosmolality [low levels of electrolytes, proteins and nutrients in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 20 residents (Resident #1) reviewed for comprehensive care plans in that: Resident #1's care plan did not address Resident #1 preferred for his tracheostomy tube's [a tube inserted through the neck and the windpipe to assist with breathing] cuff to be deflated. This deficient practice could affect residents and place them at risk for insert applicable risk/ in residents not receiving appropriate treatment and services or activities: The findings were: Record review of Resident #1's face sheet, dated 1/18/24, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of essential (primary) hypertension, chronic viral hepatitis c [a viral infection that causes liver inflammation], chronic respiratory failure with hypoxia [low oxygen levels in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 20 residents (Resident #19) reviewed for storage of drugs. Resident #19's Novolog [a type of injectable, short-acting medication that helps control high blood sugar levels] insulin pen was left unsecured and unattended on top of the 100 Hall nurse medication cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Record review of Resident #19's face sheet, dated 1/19/24, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of hypokalemia [low levels of potassium in the blood], vascular dementia [brain damage typically caused by multiple strokes], mild, without behavioral disturbance, psychotic disturbance[a disconnection from reality], mood disturbance, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 20 residents (Resident #1, Resident #20, and Resident #5) reviewed for infection control in that: 1. Prior to performing Resident #1's tracheostomy [a hole in the neck and into the windpipe to assist with breathing.] care, RT A did not maintain sterile technique when putting on sterile gloves. 2. While performing Resident #20's tracheostomy care RT B placed a contaminated split 4x4 gauze on Resident #20's tracheostomy. 3. While performing Resident #5's incontinent care, CNA D did not perform hand hygiene between glove changes. This deficient practice could affect all residents and place them at risk for infection. The findings were: 1. Record review of Resident #1's face sheet, dated 1/18/24, revealed Resident #1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials which included to the State Survey Agency, in accordance with State law through established procedures for one (Resident #1) of 5 residents reviewed for abuse/neglect. The facility staff did not report a fall Resident #1 sustained a fall on 12/17/2023 during an attempted transfer when CNA B opted not to follow facility policies and procedures which require a 2 person physical assist. This failure could place residents at risk for abuse or neglect. The findings include: Record review of Resident #1's electronic facesheet revealed the Resident #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 resident (Resident #1, and Resident #2) reviewed for care plans. 1. The facility failed to develop a person-centered care plan for Resident #1 that would addresss resident's activities of daily living including transfers until after a fall on 08/09/2023. 2. The facility failed to ensure Resident #2's care plan was implemented for bed mobility resulting in a fall on 09/18/2023. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: 1. Record review of Resident #1's face sheet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 (Resident #182 and Resident #13) of 22 residents reviewed for advanced directives, in that: 1. Resident #182's OOH-DNR form was improperly executed via verbal consent and not signed by the resident's representative. 2. Resident #13's OOH-DNR was improperly executed by a physician rather than the resident's representative. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. The findings were: 1. Record review of Resident #182's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Acute and Chronic Respiratory Failure with Hypoxia, Encounter for Attention to Tracheostomy, and Schizophrenia. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #10) reviewed for notifications. The facility failed to notify Resident #10's guardian that he was sent to the hospital. This failure could place residents at risk for their rights not being honored and could result in mental anguish, frustration, and anxiety for the resident and the family. The findings included: Record review of Resident #10's face sheet dated 3/16/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. His diagnoses included unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without return to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise a person-centered care plan for 1 of 22 Residents (#66) in that: 1. The facility failed to revise a comprehensive care plan that addressed Residents #66's Do not resuscitate (DNR) order status. This deficient practice could place residents at risk of not having a change in code status followed by the facility. The findings included: Record review of Resident # 66's face sheet dated 03/16/23 revealed the resident was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood), peripheral vascular disease ( a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes mellitus (a condition that affects the way the body processes blood sugar). Record review of the Physician order summary dated 3/16/23 for Resident #66 revealed a physician's order for DNR status made on 1/27/23. Record review on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure that the four (4) of the food container items in the storeroom were labeled with by use dates. This failure could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings included: Observation on 03/14/23 at 10:05 a.m in the kitchen storeroom revealed there were three seven (7) lb cans of My Hometown Vanilla Pudding and one (1) six (6) lb can of Red Pack Sloppy [NAME] Sauce that were undated. Interview with the Dietary Aide (DA) on 03/14/23 at 10:10 a.m. who stated that all four containers of food were not dated. The DA stated that the Vanilla Pudding had been in the kitchen storeroom since 03/10/23 and the Sloppy [NAME] Sauce had been in the storeroom since 03/07/23. When asked about the risks associated with food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to provide resident abuse prevention training to 4 of 25 staff reviewed including ( C.N.A. LVN, RN staff, and the Activity Director). The facility failed to ensure that 4 of 29 staff reviewed had completed their mandatory abuse annual training. This deficient practice could place residents at risk for care by C.N.A., LVN, and Activity staff who have been insufficiently trained while working in the facility. The findings included: Record review of the annual C.N.A., LVN, RN, and Activity training information provided by the Administrator revealed that C N.A-E(hired-5/30/18) , LVN-A (hired-4/2/20) , RN-C (hired-9/1/21), and the Activity Director ( hired-10/21/14), had not completed their mandatory abuse annual training During an interview with the Administrator and RN-A on 3/16/22 at 2:25pm the Administrator stated that there was not a record of a annual abuse training for C N.A-E, LVN-A, RN-C and the Activity Director. Record review of the facility policy on Staff Development Program dated 2001 noted that staff must complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 25 staff (CNAs D, E, F, H, I, J, RNs B and C, and LVNs A and B) reviewed for training, in that: The facility failed to ensure that 10 of 25 staff (CNAs D, E, F, H, I, J, RNs B and C, and LVNs A and B) staff had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA, RN, and LVN staff who have been insufficiently trained while working in the facility. The findings included: Record review of the annual CNA, LVN, and RN training log revealed that: CNA D (hired-3/13/19), CNA E (hired-5/30/18), CNA (hired-6/27/19), CNA H (hired-4/6/11), CNA I (hired-1/11/07), CNA J (hired-4/15/21), RN B (hired-7/16/08), RN C (hired-9/1/21), and LVN A (hired-4/2/20), and LVN B (hired-10/7/19) had not completed their mandatory QAPI annual training During an interview with the Administrator and RN #1 on 3/16/22 at 2:25pm the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to provide effective behavioral health mandatory training for four (4) of twenty-five (25) staff reviewed including C.N.A, LVN staff and the Activity Director. The facility failed to ensure that 4 of 25 staff had completed their mandatory behavioral health annual training This deficient practice could place residents at risk for care by C.N.A.,LVN, and Activity staff who have been insufficiently trained while working in the facility. The findings included: Record review of the annual C.N.A., LVN, and Activity training log revealed that C N.A-G (hired-4/3/19), C.N.A-H (hired-4/6/11)), C.N.A.-K (hired-1/13/20), LVN-B hired 10/7/19), and the Activity Director (hired 10/21/14) had not completed their mandatory behavioral health annual training During an interview with the Administrator and RN-A on 3/16/22 at 2:25pm the Administrator stated that there was not a record of a annual behavioral health training for C N.A-G, C.N.A-H, C.N.A.-K, LVN-B, and the Activity Director. Record review of the facility policy on Staff Development…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.